Patient Note (Troy)
Troy
(Patient ID 040)
| Name: Troy | Age: 79 | Admit date: 2 weeks ago | MR #: 000-040 |
| Gender Identity: Male | Race: Caucasian |
Admitting diagnosis: CVA |
Insurance: Medicare |
| History of present illness: Troy was admitted to this inpatient rehabilitation center 2 weeks ago s/p R CVA with resulting L UE hemiplegia and LLE weakness. Client with decreased sensation to LUE and LLE and persistent L lean. Client with weakened swallow and current aspiration precautions. | |
| Past medical/surgical history: Dementia and chronic abdominal pain with etiology unknown. |
| Employment/work/school: Troy has been married to his wife for 57 years. They have two children and six grandchildren. His children and grandchildren are involved and several are available locally for support. Troy is a retired engineer. Troy’s Christian faith is important to him and his wife. They have strong social support from their local church. Troy enjoys making coffee for him and his wife in the mornings and going out to eat together. Troy and his wife divide the house chores. | |
| Prior level of function: Modified independent with all ADLs and most iADLs, extra time required. Troy has not driven since the year before his diagnosis of dementia, about 5 years ago. | |
| Living situation/environmental barriers: Prior to the inpatient rehab stay, Troy lived with his wife in a one-story home with 3 steps to enter. Their home has a walk-in shower with a small step. |
Aspiration precaution
OOB, seated in chair for all meals
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.